HOW IT WORKS
Principia is an NHS England new care model vanguard. This multispecialty community provider’s first initiative was to design and implement an enhanced care program to improve outcomes and experiences for frail elders living in care homes (facilities that provide housing, meals, supervision, and help with personal care needs). Care home residents are automatically eligible for the program if they are registered with a GP practice within Principia. The program has four key elements:
- Enhanced general practice care specifications, including regular GP ward rounds, access to electronic health records (EHRs), individual care and end-of-life planning, and medication reviews.
- Enhanced community nurse support and falls therapy, including a designated community matron and nursing team and “bite sized” training for care home staff.
- Independent information and support for alignment and advocacy, facilitation of care home managers network meetings, and volunteers within the home.
- Engagement of care home managers, including engagement with the Clinical Commissioning Group and shared ownership/hosting of network meetings.
The program’s enhanced care package also includes identification of a designated GP practice and regular planned visits for each care home, with support from community nursing and therapy teams, pharmacists, dieticians, social service organizations, and the voluntary sector.
Principia is currently responsible for just over 900 beds across 23 care homes. The program has been replicated elsewhere. Activity data is routinely collected, and the program has been evaluated externally. For 650 residents in Rushcliffe Care Homes, there have been cost savings of nearly £64,000 for care home medication reviews and nearly £63,000 for care home dietetic reviews (2016–17).
For providers: The program requires a large commitment from GP practices as well as a huge cultural shift: patient care is everyone’s responsibility, not just the care home’s. Key elements of Principia’s approach to integrated care are: aligning one practice to one care home; planned patient review meetings and visits; monthly operational meetings with all stakeholders; medication reviews supported by the Medicines Management Team; dietetic reviews; dietetic training for care home staff; and a collective responsibility for ensuring high-quality care. The development of templates and clinical pathways, which are embedded into GP computer systems, have supported the aim of providing standardized, high-quality care. While a range of health and social care staff are involved, care is always provided in the care home itself. Most data-sharing is currently handled verbally, but there are plans to embed a computer system in care homes that links to, and extracts relevant real-time patient information from, the GP computer system. This would allow patient information to be transferred securely between all designated integrated care providers and the care homes.
For patients/caregivers: Patients, relatives, and caregivers have the opportunity to share in care planning and are invited to be involved in all clinical decisions. Caregivers are engaged informally during ward rounds and encouraged to join stakeholder groups, such as quarterly meetings to discuss views on treatment of family members.
During the first three years, the organization Age UK was instrumental as an independent advocate for both the care homes and the registration of patients with the GP practice aligned to the care home. It supported a safeguarding role, helping to identify possible issues related to abuse, harm, or neglect. It also served as an independent advocate for care homes and residents. A multidisciplinary team of health and social care stakeholders meet during monthly operational meetings to discuss best options for each patient.
The National Health Service and the new care model MCP Vanguard program both fund Principia as part of an initiative supporting new models of care. The program creates a local partnership of general practices, patients, and community service providers. GPs receive enhanced payments for the additional work undertaken and increased clinical capacity needed to support the program.